Inquest jury finds that delay in getting medical care and the impact of over exertion during struggle
15 Sep 2016
On 18 April 2011, Michael Sweeney died in the Royal London Hospital under police restraint.
The Metropolitan Police Service was called to the Approach Tavern in East London in response to a report that a severely agitated man was carrying a knife and refusing to leave. The first officers arrived at 19.34. Mr Sweeney had already put the knife down. Witnesses who gave evidence from the pub all said that Michael had not threatened anyone but was preoccupied that someone was after him.
The police took Mr Sweeney into custody and put him in the back of a police van where he became increasingly agitated and disturbed. They quickly identified that Michael was suffering from excited delirium (otherwise known as acute behavioural disorder) which they understood was a life threatening condition. They called an ambulance at 19.39. A controller from London Ambulance Service (LAS) gave evidence that their operators have no training on excited delirium, and that at that time ambulances called through the police computer (CAD) system were only prioritised on the basis of yes/no answers to five questions (severe bleeding, conscious, breathing, chest pain or shot/stabbed). Further information provided to LAS by the police controller was not passed on, and there was no-one to analyse it even if it was.
Michael was therefore graded as a C1 (amber) case with a response time of 19 minutes. However, no ambulance was available. The police waited until about 19.59 before making the decision to transport Mr Sweeney to the nearly Royal London Hospital, in the van as an emergency on blue lights. The CCTV from the hospital records the van arriving at 20.01. However, Mr Sweeney was not brought into the resuscitation room from the ambulance bay until 20.27. Nursing staff and some medical staff gave evidence that they did not know about the condition called excited delirium.
From his first contact with police, Mr Sweeney was held handcuffed. He was reported to be rocking the police van from side to side, struggling against the cuffs, banging his head and shouting. He was sweating profusely and he removed his clothes. In resus, Mr Sweeney was held face down by officers while medical staff began sedating him in stages. Once sedated, at about 20.45, Mr Sweeney was turned onto his back. He immediately went into cardiac arrest. He was resuscitated but he shortly afterwards arrested again and died.
The jury listened attentively to evidence from 39 witnesses over nearly three weeks and today they concluded that Mr Sweeney’s death was accidental but contributed to by restraint and struggle and acute behavioural disorder. In a narrative verdict they concluded the following:
“The failure in the time delay getting Michael Sweeney (also known as Michael Bishop) medical assistance/care had the impact that resulted in the over exertion during Michael’s struggling and being restrained.”
Michael’s brother David Bishop says:
“It is hard to come to terms with the circumstances in which my brother died, and like the jury I am left with the view that the outcome may have been different if the duration of struggle and restraint had been brought to an end sooner by more rapid medical treatment and sedation.”
The family’s solicitor, Kate Maynard, says:
“Excited delirium is a fairly newly understood condition which the police are trained to recognise as a medical emergency because it can lead to sudden death. The Coroner said that she would write a report aimed at preventing future deaths in circumstances such as these. However, it is a concern that this will apparently suggest that the police should move away from using the term excited delirium or acute behavioural disorder, instead referring to the more generic term “extreme agitation”. That may not convey the same sense of urgency, and may represent a retrograde step. It was the ambulance, nursing and medical staff who preferred the term “extreme agitation”, but they (unlike the police) had not had any training in the condition.”